KKH disciplines staff involved in incident

The KK Women's and Children's Hospital (KKH) has pinpointed a lapse that could have led to the swopping of two babies last month, and taken several staff to task.

At a media conference yesterday, KKH said the incident was triggered by a series of errors, including placing the two babies in the wrong cots and not checking the babies' ankle identification tags during the discharge process (see sidebar).

The hospital also disciplined three nurses who were directly involved in the incident, as well as their two supervisors.

In total, 17 staff working in the ward where the mix-up occurred were given warnings or counselled.

Professor Kenneth Kwek, KKH's chief executive, said the staff did not adhere to protocol, but said that the oversight was an isolated incident.

After speaking to the staff, he said some felt that as there were many layers of checks, they did not think anything would go wrong.

So, they felt that it was not so essential to do checks on their end.

"This is the message we need to get across to our staff... When it comes to patient identification and patient care, you must be accountable for your own actions, not rely on your colleagues," Prof Kwek said.

Following the incident, KKH stepped up measures to tighten its process of identifying newborns, by implementing the 15 recommendations made by a four-member review committee which was convened to look into the incident (see sidebar).

KKH will also enforce additional measures, such as informing the mother when a baby's tag is replaced and getting her to verify that it has been done correctly.

Prof Kwek said that the hospital has been in touch with the affected parents and will "compensate them for the suffering and distress they have gone through".

When asked to specify, he said KKH has offered the affected families some compensation that went beyond waiving the hospital fees, but would not furnish details.

He declined to reveal if the families have accepted the offer, citing their request for confidentiality.

Calling the lapse "unacceptable", the Ministry of Health (MOH) said yesterday that it issued a stern letter to Prof Kwek to convey its disappointment and concern over KKH's oversight and lack of supervision.

MOH added that an inspection of public and private hospitals late last month found all of them to be adequate in their policies, structures and protocols for tagging and verifying babies' identities after they are born.

An MOH spokesman said the KKH incident was a reminder to all health-care institutions here to "strengthen their qualityassurance programmes to improve patient safety and outcomes".

What happened

The two infants in the mix-up, Babies A and B, were placed in the wrong cots.

But the review committee could not find out precisely when this happened.

The wrong ankle identification tag was used for one of the infants, Baby A.

Baby A's tag fell out and was replaced with Baby B's tag, which likely happened because Baby B had an extra tag printed.

The extra tag came about because a staff member had earlier asked a colleague to print Baby B's tag, as she did not have access to do so.

Since this was not done quickly, she asked another colleague to print the tag.

The extra tag for Baby B was somehow used for Baby A. Nurses had failed to verify the babies' ankle tags at critical points.

For instance, during the discharge process, the two nurses involved admitted that they did not check both babies' tags.

Closing gaps

Identification of newborn babies

Two staff, one of whom must be a registered nurse, will be involved in the tagging and re-tagging of babies at all times.

There will be proper documentation of the replacement of dislodged tags in clinical notes.

Cards used for babies' cots will be redesigned, so that only essential identifiers, such as the mother's name and identification number, are displayed prominently.

Other information, such as the baby's weight and height, will be removed.

The new cards will be used next month.

Ward operations

The roles and responsibilities of staff working in the nursery and the ward will be defined clearly.

There will be proper documentation for tracking the movement of babies in and out of the nursery.

Discharge process Both the nursery and the ward staff will be involved in discharging the baby to the mother.